Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition: Child maltreatment
Actions to take:
Interview the child separately from the parents
Ask a parent, away from the child
Parameters to monitor:
Signs of fear or apprehension from the child when either parent is present
Negative comments about child from either parent.
Rationale:
Potential Condition: Child Maltreatment
The client’s history of multiple injuries (bloody nose, sutures from hitting cabinet, and spiral fracture) in the context of the parent’s alcohol intoxication, slurring, and aggressive behavior raises concern for possible child maltreatment. The child’s statement about being "clumsy" and the observed scars also support the need for further investigation into possible abuse.
Actions to Take
Interview the child separately from the parents: To ensure the child can speak freely and report any concerns without the influence or presence of the parents, especially when maltreatment is suspected.
Ask a parent, away from the child: The parent should be interviewed privately to assess their behavior and any possible stressors or issues that could indicate abuse or neglect, especially considering their appearance and actions when visiting the child.
Parameters to Monitor
Signs of fear or apprehension from the child when either parent is present: This could indicate emotional distress or fear related to the parent’s behavior. It is important to observe how the child reacts to the presence of each parent during assessments.
Negative comments about the child from either parent: Verbal abuse or negative comments can be a red flag for emotional abuse or neglect. Careful attention should be paid to any signs of verbal maltreatment.
Potential Diagnoses: Incorrect Choices
Muscular Dystrophy: While this could explain a pattern of injury due to muscle weakness, it does not align with the history of multiple injuries caused by trauma or the current family dynamics.
Constipation: No evidence or symptoms supporting constipation were observed in the current assessment.
Strabismus: No direct evidence to suggest strabismus in the child’s history or exam.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. There is no indication that the child has a contagious infection, so airborne isolation is unnecessary.
B. Increasing fluid intake can worsen edema in nephrotic syndrome, as it may contribute to fluid retention.
C. In nephrotic syndrome, reducing dietary sodium intake is typically recommended to help manage edema, not increase it.
D. Corticosteroids are the standard treatment for minimal change nephrotic syndrome to reduce inflammation and protein loss in the urine.
Correct Answer is C
Explanation
A. Concrete thinking occurs during the concrete operational stage (7-11 years old), where children focus on tangible, real-world situations.
B. Egocentric thinking is characteristic of the preoperational stage (2-7 years old) and is when children have difficulty understanding others’ perspectives.
C. Abstract thinking occurs during adolescence and allows individuals to think hypothetically, reason logically, and understand complex concepts that are not tied to concrete experiences.
D. Preoperational thinking occurs in early childhood (2-7 years old), which is characterized by limited logic and the inability to think abstractly.
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